This question arises frequently. Many phyisicians order or want "EV Only" exam. It is our practice that we nearly always do transabdominal preceding endovaginal imaging as there can easily be pathology out of the field of view of the EV transducer.

It is also not uncommon in certain circumstances that the endometrium is seen better transabdominally.

don't invent an endometrium

When assessing for postmenopausal bleeding, it is essential that you get a quality look at all of the endometrial canal and measure the thickest portion.

Remember: Ultrasound will NOT be successful in all cases!

It is okay to dictate: "Endometrial canal was not seen in it's entirety. Where visualized it measures up to XX mm. Consider MRI or biopsy for further evaluation."

why is the postmenopausal endometrium often difficult to see?

As patients age, the vaginal tissue including the fornices atrophy.

To opitmally image endovaginally, the probe needs to sit in the fornix, but due to this atrophy, it will often sit directly on top of the cervix, making imaging limited